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The world’s internet penetration rate is increasing yearly; approximately 25% of the world’s population are internet users. In Asia, Taiwan has the fifth highest internet usage, and has an internet penetration rate higher than the world average. Electronic health (eHealth) literacy is the ability to read, understand, and utilize Web health information. eHealth literacy is gaining attention worldwide.
This study aimed compare the differences in eHealth literacy between traditional college students (aged between 18 and 22 years) and older adult students (aged between 55 and 72 years). It also summarizes the experiences and performances of these 2 groups in terms of searching online health-related information.
A mixed-method approach was used, including questionnaire surveys and interviews. A total of 208 respondents were interviewed: 65 traditional college students (31.3%) and 143 older adult students (68.7%). The results of the interviews were used to compare the eHealth literacy scores of the 2 groups.
There were significant differences in the overall eHealth literacy scores (
Traditional college students preferred esthetically pleasing health information, whereas older adult students focused on its promotion. Furthermore, the first group often used websites for solving health problems, whereas the second group forwarded health information through communication software.
Electronic health (eHealth) literacy is gaining increasing attention worldwide. Individuals with eHealth literacy have better health capital and can further promote the overall health and competitiveness of their countries. In 2017, the Taiwan Broadband Internet Usage Survey reported that results from 3153 valid sample analyses showed that individuals were accustomed to having an internet access rate of over 83%. Of these individuals, 84.7% agreed that “the use of the Internet has improved the quality of your life.” However, 55.9% disagreed with the statement that “the use of the Internet can increase your trust in information” [
Given the popularity of the internet, research has shifted focus toward the relevance of health literacy through the internet; as a result, “eHealth Literacy,” as a field of research, has gradually received increased attention [
Health literacy includes 3 dimensions [
eHealth literacy has the potential to positively support consumers’ health empowerment [
Eysenbach and Köhler [
Compared with younger adults, older adults had less confidence in eHealth resources, information-seeking skills, and the ability to evaluate and act upon online health information [
In Taiwan, nearly half of traditional college students use internet health information as a conduit for self-diagnosis [
Taiwan has made improving the health literacy of adults a cornerstone of national health policy. At present, the research on health literacy–related topics mostly focuses on the preparation of measurement tools [
This study uses a sequential mixed-method design. Such a design uses qualitative and quantitative research sequentially, depending on the purpose or problem of the study. The purpose is both to attain “complementarity,” such as the rationality of quantitative data in additional sampling, and to further research through qualitative study [
In this mixed-method study, the research process was divided into 2 phases. First, an eHealth literacy instrument (a questionnaire) was used to investigate the participants’ current situation. In this first stage, 2 classes of traditional college students in the general education program were assessed. Moreover, 3 classes of older adult students (aged 55 years or above) who were enrolled in a university-affiliated, formal, unaccredited, voluntary, lifelong learning program participated in this study. The older adult students who participated had at least an elementary school education; some studied at the senior high school level, although not all attained a diploma and none had a college degree. Data were collected from an urban university in Taiwan. Before the study, the program was reviewed and approved by the university’s institutional review board (ethics committee). Of the 208 respondents, 65 (31.2%) were traditional college students (aged between 18 and 22 years) and 143 (68.7%) were older adult students (aged from 55 to 72 years).
The answers to the questionnaire were evaluated to select prospective respondents as the second phase interviewees. The participants were chosen from a voluntary sample (see
Demographic data on the interviewees.
Interviewees, gender | Age (years) | Educational level | |
Male | 20 | Studying at university (sophomore, the second year of college) | |
Male | 20 | Studying at university (sophomore, the second year of college) | |
Male | 19 | Studying at university (freshman, the first year of college) | |
Female | 21 | Studying at university (junior, the third year of college) | |
Female | 20 | Studying at university (sophomore, the second year of college) | |
Male | 57 | Senior high school | |
Male | 62 | Junior high school | |
Female | 70 | Junior high school | |
Female | 59 | Senior high school | |
Female | 68 | Elementary school |
The eHLS measures a student’s ability to seek, find, understand, and evaluate health information from electronic sources and to apply this knowledge to address or solve a health problem [
One of the aims of this study was to try to capture the experience of the use of online health information for college students and older adult students. To do so, this study examined the participants’ health literacy levels based on Nutbeam’s [
Descriptive statistics and
Interview guide items.
Focus point, open questions | The concept of health literacy | |
What kind of online health information are you more interested in? | Basic ability to read health information ( |
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What kind of source for online health information are you more interested in? | Knowledge of a supportive, interactive environment that provides health information ( |
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How would you evaluate your internet health information reading and implementation experiences? | Basic ability to read and use health information ( |
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How do you assess the accuracy of health information? What is the assessment principle? | Both criticism of health information and its application to one’s health |
Coding and categorization examples.
Main category, subcategories, axial coding | Open coding | ||
College students access most online health information from Web pages [A-2-64] | We college students retrieved most online health information from Web pages. [A-5-31] The most commonly used Web pages or websites are the occasional Yahoo News health section. [A-2-64] |
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Older adult students often obtained online health information through communication software [B-5-11] | We have a Line group in the class; every day we share messages. [B-5-11] Computers are used less now, as mobile phones are the most convenient. We often use communication software to share health information. [B-4-15] |
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Traditional college students | At University, my friends always pay special attention to their appearance, so I pay special attention to my looks. [A-1-28] |
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Older adult students | Since retirement, I pay special attention to diet and health issues such as exercise and fitness It is good for health. [B-3-5] |
The interview addressed the issue of participants’ experiences in accessing online health information and focused on the concept of health literacy. In the process of data analysis, an academic peer was invited to use the code and test its relevance to meet the consistency and reliability requirements of qualitative research.
The purpose of this study was to understand the ways that subjects perceive their experiences. Therefore, the researcher played the role of “listener” in the interview process and did not make value judgments while conducting the interviews. Coding and categorization examples are shown in
There was a significant difference in the overall eHealth literacy scores between traditional college students and older adult students (
The initial motivation for college students to access online health information was to meet the needs of beauty, weight loss, fitness, and so on:
Before in high school, I had a face full of acne and now have pockmarks. Now, at University, my friends always pay special attention to their appearance, so I pay special attention to my beauty.
Girls always want to have a good body shape...You may see someone post on the Internet about how they succeeded in losing weight. When we see a successful experience in which someone loses weight quickly, no matter whether it is true or not, we want to learn from them.
Electronic Heath Literacy Scale means, SDs, and
Factor | Traditional college students (N=65), mean (SD) | Older adult students, (N=143), mean (SD) | The assumption of equal variances | |||
Functional electronic health literacy | 11.43 (1.94) | 8.08 (1.56) | 3.706 | .06 | 12.17 (206) | <.001 |
Interactive electronic health literacy | 14.50 (2.67) | 14.60 (2.52) | 0.100 | .75 | −0.263 (206) | .79 |
Critical electronic health literacy | 17.81 (3.74) | 18.18 (3.28) | 3.214 | .08 | −0.71 (206) | .48 |
Electronic health literacy | 43.78 (6.68) | 40.93 (5.10) | 3.711 | .06 | 2.98 (206) | <.001 |
Furthermore, the online health information retrieval methods of college students can be divided into
The most commonly used site is the occasional Yahoo news health section, on things like healthcare, healthy food, health exercises, and clicking on links to help with acupuncture points and the like, such as ah-shi acupuncture points for the eye.
I often use Yahoo or Google and get many results from forums...just by looking at a forum or seeing someone share an experience. Message-board posts can only be used as reference points that are not easy for individuals to adopt. This is because everyone has a different living environment and because the retrieved information cannot be used for all situations.
Respondents were most interested in reading online health information. When browsing health information, most of the information available online was not sufficiently clear or too specialized. Moreover, most respondents asserted that they understood the health information on the internet, but some proper nouns, foreign language terms, and various ways in which data were presented made it difficult for some respondents to understand and learn from adverse outcomes:
Most of the online health information is easy to understand and does not appear [for example] like a book that is written very professionally and difficult to read. Getting information from the Internet is very convenient, [because] you can quickly know the information and it will not be difficult [to understand].
Furthermore, the criteria for assessing the quality of online health information can be divided into 2 categories: subjective judgment and objective form.
There is some very obviously illogical [information that] I will not go to, at least with the mind to question it. For example, burn soy sauce, or wipe pepper on your skin for weight loss, but you would think that this will only hurt your skin.
On the other hand, the
Reading numbers, small ads...If the site appears with too many small ads, that is, with commercial activity, [with an intent] to sell some things, I will not accept it.
I will check information from an accredited institution...[If called to choose] [b]etween information available for 2005 and 2009, I would rather believe information from 2009, because it is relatively new. The content is really a relatively large problem; I will pay attention to the source...If it is just the Central Research Institute meeting with a doctor, I will ask that day to see that...that perspective?
Online health information used by older adult students was mostly concerned with “diet and nutrition,” “health and wellness,” and “exercise and fitness”:
Before, when I was working, I was often busy when I ate, so I did not pay attention to nutrition, had no time to exercise, causing me to be physically ill often, and also susceptible to catching a cold, and now, after retirement, I pay special attention to diet and health issues such as exercise and fitness. I think exercise [is important] for your health.
Besides, older adult participants had access to a communications software group, enabling them to access online health information via group sharing:
We have a Line group in the class, [and] every day we share messages. Last month a student was sick and suddenly died. We are already into old age, so we all attach great importance to health problems, and if we do not maintain our health, we will soon meet God. So, we have a bunch of health messages every day to share with each other, every day mobile phone messages to forward.
I am now sixty years old, at the age when I begin to face what old, sick, dead, and living must go through, when you hear friends around who get sick and then survive, they become more self-alert. Computers are used less now, as mobile phones are most convenient, I now have time to draw...We often use communication software to share health information to friends and relatives, in the hope that people can keep healthy.
The above data indicated that the majority of older adult students had retired from work and had more time to pay attention to their health, focusing more on their “diet and nutrition,” “health and wellness,” and “exercise and fitness.” Their primary source of information was mobile communication software through which they shared health messages.
Most of the respondents believed that they had no problem with reading comprehension. However, most of the older adult students observed that they had lower critical ability and difficulty distinguishing correct information from incorrect information. Therefore, they believed that most health information was not very reliable as a reference:
There are a lot of opportunities to share health information, [and] reading comprehension is not a problem. I am also interested in the content, but some of the information overlaps, and I cannot evaluate the accuracy, so the reference value is reduced. Also, I have to follow the practice of health information. But the effect [once the information is applied] is not as favorable as the health information itself, so for these messages, after reading the reference, the effect is more difficult to control.
Older adult students primarily based their assessment of information accuracy on both subjective judgment (such as individual experience or previous knowledge) and objective standards (such as sources, publication date, or professional authorship). These respondents used implicit perceptions of their own experiences and subjective judgments as well as explicit perceptions, such as information from experts and cross-validation of information from credible institutions:
Online health information needs to be cross-verified for correctness through different channels, such as seeking formal medical information medical information or asking a medical professional.
In the overall assessment of eHealth literacy, traditional college students scored higher than older adult students. The results indicate that eHealth literacy varies across generations. eHealth literacy has multiple levels [
This study found that traditional college students and older adult students accessed online health information differently. Young adult college students accessed online information from websites and focused mostly on “beauty,” “weight loss,” and “fitness.” These topics typically concern physical appearance. Older adult students accessed online health information generally through communication software, enabling them to share more health information. The health information older adult students tended to access included information about diet and nutrition, health and wellness, and exercise and fitness.
Moreover, most of the study participants had expressed the belief that the majority of online health information could be read and understood. However, when evaluating the quality of information, they were generally doubtful. Participants pointed out that the quality of online health information is divided into subjective judgment and standard objective information. However, some participants in each group suggested that, in the era of information explosion, it is not easy to choose and determine the accuracy of the information. Thus, the participants tended to take a skeptical attitude if they were personally involved and would then find additional resources to verify through multiparty comparison to enrich their knowledge and understanding of the topic. This finding is similar to the findings in the study by Hsu et al [
Furthermore, in study 1, functional eHealth literacy scores were different for traditional college students and older university students, but interactive and critical eHealth literacy scores did not differ. Empirical evidence has shown that an inverse correlation exists between age and eHealth literacy [
This study has several limitations. First, the study was performed under trial conditions in which it was expected that the participants would answer hypothetical questions that were not clear and did not directly address the participants’ actual physical health concerns. Second, this study found that both younger college students and older adult students were capable of reading and understanding online health information to some extent. The participants did have basic eHealth literacy. However, both groups experienced difficulties in recognizing correct health information online. Given that we did not observe the highest level of critical eHealth literacy, the data collected through our investigation may not have been specific enough. Furthermore, the interviewees constituted a voluntary sample of 5 participants, which likely affected the generalizability of the results.
This study found that functional eHealth knowledge varies across age groups, unlike interactive and critical scores. Higher levels of eHealth knowledge are more difficult to cultivate and evaluate [
This study explored the effect of age on eHealth literacy in the hope that the findings will stimulate further debate about how a health education framework can be translated into practical approaches and contribute to the further refinement of the eHealth literacy concept. In the eHealth literature, this is the first study to explore whether group differences exist.
The findings showed that there are gaps in eHealth literacy between traditional college students and older adult students. Therefore, we recommend that the education system strengthens the functional and critical eHealth literacy of both groups. These age disparities have been attributed to older adults’ unique health needs (eg, “diet and nutrition,” “health and wellness,” and “exercise and fitness”) as compared with younger adults [
Due to different personal eHealth literacy experiences, to develop specific strategies for promoting individualized health literacy, it is necessary to know about the current health concerns of different individuals not only to design eHealth learning programs but also to empower individuals in planning them. The study observed that participants, when faced with challenging and uncertain health situations, employed various strategies to reduce ambiguity about a health-related condition. Furthermore, based on Nutbeam’s original conceptualization, Paige et al [
Moreover, literacy, numeracy, decision-making, and reasoning skills may be needed for the critical evaluation of the retrieved information by each group of students [
The eHealth Literacy Scale.
electronic health
electronic Health Literacy Scale
Uncertainty Management Theory
This research is supported by the Ministry of Science and Technology of Taiwan, project number MOST 106-2511-S-151-003.
None declared.